In your experience, what conditions are actually more/less important than they seem in 1st/2nd year?

[Kerosene Hat]

In other words, what conditions do residents/attendings want you to think more/less about than you would think up to Level/Step 1?

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[mistafab]

All those conditions you don’t think are important are actually really important. If you cut corners it shows up in M3, and I imagine beyond that as well.

 

[Kerosene Hat]

All those conditions you don’t think are important are actually really important. If you cut corners it shows up in M3, and I imagine beyond that as well.

Ugh, I absolutely didn't mean to suggest cutting corners or anything nefarious. I'm not saying any condition isn't important, but has an attending/resident ever scolded you for putting things at the top of differential diagnosis lists that tend to be diagnoses of exclusion, etc.? Things that tend to be answers to preclinical test questions, but are only considered after a multitude of tests, etc.?

 

[BigRedBeta]

Quite honestly, it's going to be hard to tell you because there may be a lot of things that get stressed at your institution in preclinical years based on PhD expertise, but that never show up anywhere else. Check with the students at your school to see what they think got too much time during preclinical blocks.

Overall, as a general rule, anything that requires a pathologist to make the diagnosis is overemphasized in the pre-clinical years. I spent hours committing all the variations of lung tumors to memory based on their differences of location in the lungs and how they appeared on microscopy as a second year...and I don't think I saw single patient with anything other than small cell lung cancer at all on intenal medicine clerkship. Between medicine and pediatrics it's way more fruitful to have a good handle on asthma then any lung cancer, lo and behold there are way more people with asthma.

 

[deleted645092]

Rare things get tested on in the preclinical years because they have distinct presentations.

As for what's important in the clinical years; Common is common. I got scolded in my first rotation for thinking a lady with night sweats and fevers with dry cough x1 week was TB. But we also did see a lady with neurofibromatosis so that was weird.

 

[ortnakas]

It’s always important to keep a wide differential but realize that common things are common. Remember what zebras look like, but that you’re mostly looking for horses.

For example- your jaundiced patient COULD have Wilson’s disease, sure, but alcoholic hepatitis, viral hepatitis or an obstructive pattern are all more likely.

 

[CougarMD]

Every time you create a differential, divide it into three categories:
1. The 1-3 things it could be that will kill this patient today (or soon)
2. The 1-3 most common things that it likely is
3. The 1-3 zebras that you learn about in medical school but rarely see.

In that order.

If you have at least one thing in each category, you are doing a pretty good job with a differential.
I see many med students who have 1 thing in category 1, three things in category 3....and completely miss category 2.

 

[Lawpy]

Every time you create a differential, divide it into three categories:
1. The 1-3 things it could be that will kill this patient today (or soon)
2. The 1-3 most common things that it likely is
3. The 1-3 zebras that you learn about in medical school but rarely see.

In that order.

If you have at least one thing in each category, you are doing a pretty good job with a differential.
I see many med students who have 1 thing in category 1, three things in category 3....and completely miss category 2.

Useful tips, thanks for this!

 

[ciestar]

Rare things get tested on in the preclinical years because they have distinct presentations.

As for what's important in the clinical years; Common is common. I got scolded in my first rotation for thinking a lady with night sweats and fevers with dry cough x1 week was TB. But we also did see a lady with neurofibromatosis so that was weird.

So painfully true lol i got that harsh reality check my first day of IM in heme/onc. But ive seen a few cases of hemochromotosis so that has been interesting.

But also: pheos.

 

[Psai]

Had like three questions on turner syndrome on step, haven't seen a single case. I've had multiple cases of nf1 and 2 as well as pheos/paragangliomas.

 

[Newyawk]

TB is pretty common in urban immigrant-heavy areas...

Where im from TB is at the top of the differential sometimes

 

[073116]

TB is so widespread. I can guarantee at least every second patient that has been in other parts of world, is immigrant or has family members that came from other country (that would be like at least 20% of US population) have TB. Most of them have it passive form, but it's there. The dude that mentioned he got scolded lol, was scolded probably not because of zebra TB disease, but because of wrong thinking. TB is not x1 week of cough.

 

[Angus Avagadro]

As knowing what normal looks like, knowing what most common abnormal looks like is just at important.

60 yo patient comes in with nasal voice and sinus congestion. Sinusitis, right? Most likely. If uvula doesn't move on HEENT exam, then better think ALS. See, knowing what common abnormal is important, so you will recognize abnormal when it shows up